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Atrial Fibrillation Is Associated with a 5-Fold Increased Risk for Stroke and Is Estimated to Cause 15% of All Strokes (2)

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Atrial Fibrillation Is Associated with a 5-Fold Increased Risk for Stroke and Is Estimated to Cause 15% of All Strokes (2) In the Clinic Atrial Fibrillation Diagnosis page ITC6-2 Treatment page ITC6-6 Practice Improvement page ITC6-14 Tool Kit page ITC6-14 Patient Information page ITC6-15 CME Questions page ITC6-16 Section Editors The content of In the Clinic is drawn from the clinical information and Deborah Cotton, MD, MPH education resources of the American College of Physicians (ACP), including PIER Darren Taichman, MD (Physicians’ Information and Education Resource) and MKSAP (Medical Knowledge Sankey Williams, MD and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP’s Medical Education Physician Writer and Publishing Division and with the assistance of science writers and physician writ- Peter Zimetbaum, MD ers. Editorial consultants from PIER and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult http://pier.acponline.org, http://www.acponline.org/products_services/mksap/15/?pr31, and other resources referenced in each issue of In the Clinic. CME Objective: To review current evidence for the diagnosis and treatment of atrial fibrillation. The information contained herein should never be used as a substitute for clinical judgment. © 2010 American College of Physicians In the Clinic trial fibrillation (AF) is the most common, clinically significant car- diac arrhythmia. It occurs when a diffuse and chaotic pattern of elec- Atrical activity in the atria suppresses or replaces the normal sinus mechanism, leading to deterioration of mechanical function. Atrial fibrilla- tion is a major cause of morbidity, mortality, and health care expenditures; prevalence in the United States is 2.3 million cases and is estimated to in- crease to 5.6 million by the year 2050 (1). Atrial fibrillation is associated with a 5-fold increased risk for stroke and is estimated to cause 15% of all strokes (2). Independent of coexisting diseases, the presence of AF confers a 2-fold increased risk for all-cause mortality (3). Diagnosis Who is at risk for atrial Is a single electrocardiogram fibrillation? sufficient to diagnose or exclude Atrial fibrillation occurs in less atrial fibrillation? than 1% of individuals aged 60 to Figure 1 is an electrocardiogram 65 years, but in 8% to 10% of those (ECG) showing AF, and it indi- older than 80 years. Prevalence is cates that a single ECG is sufficient higher in men than in women and to diagnose AF provided it is higher in whites than in blacks (1). recorded during the arrhythmia. The risk for AF increases with the However, AF is often paroxysmal, presence and severity of underlying so a single ECG showing normal heart failure and valvular disease. rhythm does not exclude the diag- nosis. Monitoring for a longer time What symptoms and signs should can be helpful when AF is suspect- cause clinicians to suspect atrial ed and the initial ECG is normal. fibrillation? In patients with daily symptoms, Some patients have prominent 24- or 48-hour continuous Holter symptoms, including palpitations, monitoring is usually sufficient to shortness of breath, exercise intol- make the diagnosis. In patients with erance, chest pain, and malaise. less-frequent symptoms, monitoring However, many patients, particular- during longer periods with electro- ly the elderly, have asymptomatic cardiographic loop recorders may be (silent) AF, including some patients necessary. However, even monitor- who have severe symptoms during ing for periods as long as a month other AF episodes (4). Symptoms can be nondiagnostic in patients are generally greatest at disease on- with very infrequent episodes. In set—when episodes are typically addition, because patients must turn paroxysmal—and tend to diminish loop recorders on after symptoms over time, especially when the begin, these recorders are not help- arrhythmia becomes persistent. ful in detecting asymptomatic ar- Symptoms result from elevation rhythmias or arrhythmia-associated of ventricular rate (either at rest or nonspecific symptoms that the pa- exaggerated by exercise), irregular tient may not recognize as being re- 1. Kannel WB, Benjamin ventricular rate, and loss of atrial lated to AF. It may take years to EJ. Current percep- tions of the epidemi- contribution to cardiac output. confirm the diagnosis of AF in ology of atrial fibrilla- tion. Cardiol Clin. some patients because they have 2009; 27: 13-24. On physical examination, signs of nonspecific symptoms and long pe- [PMID: 19111760] AF include a faster-than-expected 2. Hart RG, Benavente O, riods between episodes. McBride R, Pearce LA. heart rate, which varies greatly Antithrombotic ther- apy to prevent stroke from patient to patient, an “irregu- Some newer devices avoid these in patients with atrial larly irregular” time between heart problems. New types of event mon- fibrillation: a meta- analysis. Ann Intern sounds on auscultation, and periph- itors detect irregular ventricular Med. 1999;131:492- eral pulses that vary irregularly in rhythms and automatically start 501. [PMID: 10507957] both rate and amplitude. recording regardless of symptoms. © 2010 American College of Physicians ITC6-2 In the Clinic Annals of Internal Medicine 7 December 2010 Figure 1. Electrocardiogram showing atrial fibrillation with rapid ventricular rate. In addition, implanted pacemakers which may someday have therapeu- and implantable defibrillator– tic implications. cardioverters with atrial leads iden- tify and record both symptomatic What other electrocardiographic and asymptomatic AF. Other new arrhythmias can be confused with devices continuously record heart atrial fibrillation? rhythms for as long as a month and Other arrhythmias that are com- wirelessly transmit data to a central monly confused with AF include si- monitoring station, where automat- nus rhythm with frequent premature ed systems interpret cardiac atrial contractions, atrial flutter, and rhythms and report diagnoses in atrial tachycardia. The key electro- real time (4a). cardiographic findings of AF are the absence of P waves and the presence What is the role of history and of an irregular ventricular rhythm physical examination in patients without a recurring pattern. When with atrial fibrillation? an irregular rhythm is present but History and physical examination the diagnosis of AF is uncertain, cli- help determine the duration of nicians should examine long record- symptoms and identify potential ings from multiple leads looking for underlying causes. Clinicians partially obscured P waves in de- 3. Benjamin EJ, Wolf PA, D’Agostino RB, et al. should seek historical and physical formed T waves and ST segments. Impact of atrial fibril- evidence of hypertension, heart lation on the risk of death: the Framing- failure, cardiac surgery, murmurs Figure 2 is an ECG of an irregular ham Heart Study. Cir- indicative of stenotic or regurgitant rhythm that might be attributed to culation. 1998;98:946- 52. [PMID: 9737513] valvular disease, and other indica- AF, but the presence of P waves 4. Page RL, Wilkinson and other features identify sinus WE, Clair WK, et al. tions of structural heart disease. In Asymptomatic ar- addition, clinicians should look for rhythm with frequent premature rhythmias in patients with symptomatic signs and symptoms of noncardiac atrial contractions. Figure 3 is an paroxysmal atrial fib- causes of AF, including pulmonary ECG of another irregular rhythm rillation and paroxys- mal supraventricular disease, hyperthyroidism, use of that might be attributed to AF, but tachycardia. Circula- tion. 1994;89:224-7. adrenergic drugs (such as those the presence of “saw-tooth” P waves [PMID: 8281651] used to treat pulmonary disease) or and a ventricular response that 4a. Zimetbaum P, Gold- man A. Ambulatory other stimulants, and use of alco- varies from 2:1 atrioventricular arrhythmia monitor- hol. A family history might identify conduction to 4:1 atrioventricular ing: choosing the right device. Circula- first-degree relatives with AF, conduction identifies atrial flutter. tion. 2010;122:1629-36 7 December 2010 Annals of Internal Medicine In the Clinic ITC6-3 © 2010 American College of Physicians Figure 2. Electrocardiogram showing sinus rhythm with frequent premature atrial contractions. 5. American College of Cardiology/American Heart Association Figure 3. Atrial flutter. Classic “saw-tooth” flutter waves are seen in all 12 leads, and the ventricular Task Force on Prac- tice Guidelines. response is mostly regular. (There is a transient change from 2:1 to 4:1 atrioventricular conduction fol- ACC/AHA/ESC 2006 Guidelines for the lowing the 12th QRS complex.) Management of Pa- tients with Atrial Fib- rillation: a report of the American College How should clinicians classify “Permanent” AF means that the ar- of Cardiology/Ameri- can Heart Association atrial fibrillation? rhythmia is continuous, and interven- Task Force on Prac- Although knowledgeable observers tions to restore sinus rhythm have ei- tice Guidelines and the European Society disagree on the answer to this ques- ther failed or not been attempted. of Cardiology Com- tion, the most accepted convention mittee for Practice The same patient may be classified Guidelines (Writing categorizes AF as paroxysmal, persist- into different categories at different Committee to Revise the 2001 Guidelines ent, or permanent (5) (Box 1). times, so clinicians should classify pa- for the Management “Paroxysmal” AF means that episodes of Patients With Atrial tients according to the current
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